Renal hyperparathyrodism

1. Ahmed Halawa
MSc PGCE MEd FRCS MD FRCS (Gen)
Consultant Surgeon
Sheffield Teaching Hospitals
Senior Lecturer
University of Sheffield
University of Liverpool

3. 16

4.  The management of Secondary HPT
 The management of Tertiary HPT
(post-transplantation)

5.  Pruritus
 Soft tissue calcification
 Bone disease
OFC, back pain, deformity, fractures
Aggravated by
Aluminium toxicity, age related osteoporosis,
Dialysis related amyloidosis of B2 microglobulin

6.  Calciphylaxis (calcific uremic arteriolopathy)
 HD or Tx
 High PTH and Ca
 Tender calf with extensive subcutaneous calcifications
leading to large area of skin necrosis and deep ulcers
 Digits and toes are affected
 Gangrene
 Treatment
- Cinacalcet
- Parathyroidectomy if PTH >600 pg/mL
The benefit of urgent parathyroidectomy has not
been demonstrated, even in CUA patients with
severe hyperparathyroidism.
- Wound management

7. • A. Confluent calf plaques
(borders shown with arrows).
Parts of the skin are
erythematous, which is easily
confused with simple cellulitis.
• B. Gross ulceration in the same
patient 3 months later. The black
eschar has been surgically
débrided.
• C. Calciphylactic plaques, a few
of which are beginning to
ulcerate.
(Photographs courtesy of Dr.
Adrian Fine. Up To Date)

8. (Photographs courtesy of Up To Date)

9. (Photographs courtesy of Up To Date)

10. Failed medical treatment to control the secondary
hyperparathyroidism in a well dialysed patient indicated by:
High PTH (elevated and non-suppressible iPTH usually
>800pg/ml)
Extensive extraskeletal calcifications or calciphylaxis
Refractory pruritis
Unexplained myopathy
High Ca with normal PTH
Hyperphosphataemia.
Tertiary hyperparathyriodism
Vit D level 25 (OH)D is >50 nmol/l (20 ng/ml).

13.  3 glands 3%
 4 glands 84%
 5 or more 13%
 Superior glands are posterior to the nerve
(more consistent)
 Inferior glands are anterior to the nerve
(less consistent)

15.  PTH
Due to bone resistance, level above 3-5 times
the absolute value is considered abnormal
 Ca (Normal or high)
 Hyperphosphataemia
 Vit D level
 No radiological investigations are required

16.  High-resolution ultrasound
o Sensitivity 65-85%65-85% for adenoma; 30-90%30-90% for enlarged
gland
o Suboptimal in pts with multinodular thyroid disease,
pts with short thick neck, ectopic glands (15-20%)(15-20%)
o May be useful in detecting Sestamibi scan negative
adenomas
 CT with contrast/thin section
o Sensitivity of 46-87%46-87%
o Good for ectopic glands in the chest
 MRI
o Sensitivity of 65-80%65-80%
o Good for ectopic glands

17.  Sestamibi
85-95%85-95% accurate in localizing adenoma in primary HPT
Poor in multigland disease
 Sestamibi-SPECT
Sensitivity 60%60% for enlarged gland and 98%98% for solitary
adenomas
Adapted from:
http://public.fnol.cz/www/3ik/data/soubory_en/frysa
k_parathyroid_glands.pdf

18. Only Required for Redo
Parathyroidectomy

19. Sensitivity (%)Sensitivity (%) 95% CI95% CI
SolitarySolitary
adenomaadenoma
88.488.4 87 - 8987 - 89
HyperplasiaHyperplasia 44.444.4 41 - 4841 - 48
DoubleDouble
adenomaadenoma
3030 2 - 622 - 62
CarcinomaCarcinoma 3333 3333
Johnson, AJR Am J Roentgenol. 2007 Jun;188(6):1706-15.
Tc-SestamibiTc-Sestamibi
Sensitivity Meta-analysisSensitivity Meta-analysis

20. Routine imaging of the parathyroid glands is
not indicated prior to the first operation

21. 99mTc-MIBI scan of clinically diagnosed secondary hyperparathyroidism.
No significant uptake was observed in either the early phase (A) or
delayed phase (B). Intraoperativly, 4 hyperplastic parathyroid glands were
identified (3½glands were removed)
Tc-SestamibiTc-Sestamibi
Sensitivity Meta-analysisSensitivity Meta-analysis
A B
Early Delayed

23. 40-year-old woman who presented with recurrent
hypercalcaemia and hyperparathyroidism after
resection of both left-sided glands.

24. 39-year-old woman with left superior adenoma
showing typical MRI signal characteristics.

26.  Assessment and treatment of sHPT should begin at
CKD stage III (estimated GFR <60 mL/min).
 The treatment at this stage includes: low phosphate
diet, vitamin D derivatives, phosphate binders,
calcimimetics, and parathyroidectomy if necessary.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-
MBD Work Group. KDIGO clini- cal practice guideline for the
diagnosis, evaluation, prevention, and treatment of Chronic
Kidney Disease-Mineral and Bone Disorder (CKD-MBD).
Kidney Int Suppl. 2009;113:S1–130.

27.  Target ranges for PTH, calcium, and phosphorus are
recommended to be in the normal range for those with
CKD stages III–V not yet on dialysis .
 For patients on dialysis, and the latest KDIGO
guidelines (based mainly on bone and mineral effects)
simply suggest PTH levels should be maintained
between two and nine times the upper normal limit of
the normal range
 Calcium levels should be maintained in the normal
range and phosphorus should be lowered toward the
normal range in dialysis patients.

29.  Follow the preventive measure suggested by
KDIGO guidelines (low phosphate diet,
vitamin D derivatives, phosphate binders, etc.).
This will be covered separately
 Cinacalcet
 Parathyroidectomy

30. Rodriguez et aL Seminars in Dialysis 28(5): 81 March 2015
Mode of action:
Effectively sensitizes the
cell to calcium and re-
establishes its ability to
suppress PTH. Cinacalcet
binds CaSR, altering its
structural conformation,
increasing its sensitivity to
serum calcium and
stabilizing the receptor in its
active state.

31. Conclusions
In an unadjusted intention-to-treat analysis, cinacalcet did not
significantly reduce the risk of death or major cardiovascular
events in patients with moderate-to-severe secondary
hyperparathyroidism who were undergoing dialysis. (Funded
by Amgen; EVOLVE ClinicalTrials.gov number,
NCT00345839.)

32. NICE guidelines (2007) review, 2013

33. Conclusions: Cinacalcet reduces the need for
parathyroidectomy in patients with CKD stage 5D, but does not
appear to improve all-cause or cardiovascular mortality.

34. Cost of Treatment
30 mg, net price 28-tab pack
= £ 125.75
Cost of Treatment
30 mg, net price 28-tab pack
= £ 125.75

35. Sheffield Teaching Hospital data file
Cost of parathyroidectomy

36.  High serum Calcium
 Persistent hyperparathyroidism after RTx
 Treatment is mainly surgical
• Phosphate binders are not suitable (they have normal or low
phosphate)
• Treatment of hypophosphatemia by phosphate supplements
increases phosphaturia and potentiates nephrocalcinosis
• They become refractory to Vit D3 therapy
• Ca supplement is not also suitable (they have normal or high
calcium)
• Most will improve within 12 months waiting for hyperlastic glands
to regress
• They tend to do well after operation compared to dialysis patients

37. Our study demonstrated systolic BP and PP reduced 2
years after parathyroidectomy and there was no
significant difference between the peri-operative all-cause
hospitalization rates. In addition, kidney allograft function
impaired temporarily 12 months after parathyroidectomy,
but recovered 15 months after parathyroidectomy.

38. In conclusion, subtotal parathyroidectomy was
superior to cinacalcet in controlling hypercalcemia in
these patients with kidney transplants and persistent
hyperparathyroidism.
2016

39. No statistical difference in the percent change in BMD at the femoral neck
between cinacalcet and placebo groups. The difference in the change in
phosphorus between the two arms was 0.45 mg/dL (95% CI: 0.26, 0.64), p <
0.001. No new safety signals were detected.
In conclusion, hypercalcemia and hypophosphatemia were effectively
corrected after treatment with cinacalcet in patients with persistent HPT after
Evenepoel et al (2014)

40. The increases in calcium and PTH and the decrease in
phosphorus levels after withdrawal of cinacalcet to
comparable values in the placebo arm support the chronic
nature of posttransplant HPT
Evenepoel et al (2014)

41. Cost of Treatment
30 mg, net price 28-tab pack
= £ 125.75
Cost of Treatment
30 mg, net price 28-tab pack
= £ 125.75

43.  Previous dialysis line generates fibrosis (damage)
 Vascular calcification (bleeding)
 Engorged neck veins (bleeding)
 Anticoagulation on dialysis (bleeding)
 Anaemia and platelet abnormality (bleeding)
 The glands are closely related to RLN (damage)
 Inconstancy of the inferior glands (recurrence)
 Supernumerary gland(s) (recurrence)
 Thymectomy (bleeding into the chest)

44.  Only 5-10% will come to
surgery
 Bilateral Neck Exploration
If 4 glands found, minimum 3 ½ glands
removed and thymectomy

45.  Undescended thymus is associated with
undescended inferior parathyroid gland
 The inferior parathyroid glands may be higher
than the superior glands, but stays anterior to
the RLN

46. Fat

47.  Hypoparathyroidism in 30% following
surgery
 PTH should be >100 pg/ml to prevent
the disease, but no guarantee
 Reduced osteoblasts and osteoclasts, no accumulation of
osteoid and markedly low bone turnover
 Induced by overtreatment of secondary
hyperparathyroidism…..It is iatrogenic
 Increased fractures and mortality

48.  No adequately powered RCT
 Recurrence
 Adynamic bone disease (ABD)

49.  Develops from third pharyngeal pouch like the
inferior parathyroid
 Has some parathyroid rests that become active
by persistent stimulation (CKD), they may
develop into a full gland.

51.  Severe hypocalcemia following
parathyroidectomy
 Sudden decrease in PTH disrupts bone
equilibrium of resorption vs. formation
 Most common in patients with severe
preexisting bone disease
 Occurred in 20% of 148 dialysis patients
undergoing parathyroidectomy in one series
Kidney Int Suppl 2003 Jun;(85):S97-100

52.  Hypocalcemia in the presence of normal or
high PTH
 2-4 days post op
 If tetany and seizures occur, they can increase
fracture risk
 Sudden heart failure has been attributed to
hypocalcemia
 Hypophosphatemia and hypomagnesemia
 Mainly seen in primary HPTH
 Hyperkalemia
 Occurs in 80% of dialysis patients post-op

53. Treatment
 Pre-operative:
 Loading with Vit D (1-2 μ tds) 2 days prior to
the operation
 Post-operative:
 Oral calcium – 2 to 4 g per day mild hypocalcemia
 IV calcium for symptomatic hypocalcemia or Ca <
7.5 – 1 amp of calcium gluconate instilled over 10 to
20 minutes followed by maintenance drip
 Continue Vitamin D and oral calcium
 Hemodialysis – use high calcium bath
 Peritoneal dialysis – add 1 to 3 amps of calcium
gluconate to each bag of dialysate

58. Prevertebral
Facia

59. RT Sup
Para

60. RLN

61. ?
RLN

62. LT Sup
Para
Oesophagu
s

63. Frozen section is highly
recommended in case of any doubt
Frozen section is highly
recommended in case of any doubt

64. Question
•I could not find the fourth gland
•It could be in the chest
Shall I do
thoracotomy in the
same setting looking
for the missing

66.  British Assocaition of Endocrine Surgeons Guidelines
http://www.baets.org.uk/wp-content/uploads/2013/02/BAETS-Guid
 Effect of Cinacalcet on Cardiovascular Disease in Patients
Undergoing Dialysis (EVOLVE study). N Engl J Med
2012;367:2482-94.
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1205624
 Lai et al. Secondary and tertiary hyperparathyroidism: role of
preoperative localization. ANZ J Surg. 2007 Oct;77(10):880-2
 NICE guidlines
https://www.nice.org.uk/guidance/ta117/documents/ta117-hyperpar